Author Question: The nurse is caring for a client who has pulled out his IV twice. The nurse has replaced the IV in ... (Read 32 times)

Pineappleeh · **on:** Jul 22, 2018

The nurse is caring for a client who has pulled out his IV twice. The nurse has replaced the IV in the left hand, and the physician has ordered restraints for the client.

Which of the following restraints would meet the legal restraint requirements for this client? 1. A leather restraint on the right hand
2. Soft four-point restraints
3. A jacket restraint
4. An elbow restraint on the right arm

Question 2

While eating lunch in the cafeteria, a nurse asks the respiratory therapist for an update on the condition of a client transferred off the unit yesterday. The respiratory therapist relates that the client's condition worsened this morning.

Which of the following is true regarding HIPAA regulations in this instance? 1. There are no HIPAA violations.
2. The nurse violated the client's confidentiality.
3. The respiratory therapist violated the client's confidentiality.
4. Both the respiratory therapist and the nurse violated the client's confidentiality.

Expo · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4
Rationale 1: The elbow restraint on the right arm would prevent the client from bending the arm to pull the IV out of the left hand. The client's movements are minimally restricted, which is a major requirement of restraints. A jacket restraint would not prevent the client from pulling out his IV and four-point restraints would be more than is needed for this client. Leather restraints are only used for the criminal or very violent client who requires very strong restraints.

Answer to Question 2

4
Rationale: Both the nurse and the respiratory therapist violated the client's confidentiality when they held a discussion, containing private client information, in a public place, and the nurse no longer has a need to know about the client's status.